Harm reduction (HR) is a set of pragmatic principles and compassionate strategies designed to minimize the harmful consequences of behaviors that place the person and the public at risk (Marlatt, 1998). The objective of HR is to decrease the harmful consequences of high-risk behaviors without requiring that the individual stop the behavior (Denning, 2000).

Harm reduction first emerged in the Netherlands in the late 1970s as a response to the limitations of traditional abstinence-only treatment approaches for illicit drug use. At that time, the Dutch government had banned the sale of needles in pharmacies in order to discourage intravenous (IV) heroin use and believed that banning the method through which people used the drug—needles—would accomplish this goal. The heroin users, however, knew they sometimes shared needles if they could not obtain clean ones, and that banning access to clean needles would only increase the frequency that drug users shared needles. In addition, IV drug users believed that many of their health problems resulted from sharing needles rather than from using heroin itself. They then launched a grassroots campaign to turn back the ban. Dutch public health officials decided that this argument was correct and they sent medical teams into the streets and parks to provide health care and clean needles to IV drug users. Several years into this HR approach, the number of drug-related deaths in the Netherlands dropped dramatically.

In 1985, in response to the AIDS epidemic, the British government introduced a program in Liverpool that offered medical care to drug users, clean drugs (methadone, morphine, or heroin), clean needles, and safe injection education to injection drug users. This comprehensive approach focused on minimizing the risk of drug use rather than stopping it. This approach was termed harm reduction. In the 1980s, HR emerged in the United States as a set of pragmatic public health strategies for reducing the spread of HIV and other risks associated with active substance use (DesJarlais & Friedman, 1993). Since then, researchers and public-health professionals have applied the HR approach to a variety of public health problems, such as nicotine use (Ferguson, Shiffman, & Gwaltney, 2006), sexually transmitted diseases (Ball, 2007; Emmanuelli & Desenclos, 2005), teen pregnancy (Flemming & O’Connor, 1993), high-risk eating behavior (Wilson, Grilo, & Vitousek, 2007), and weight management (Westermeyer, 1994).

Harm reduction is not a treatment in the way we usually think of treatment of a mental health condition. First, the goals of harm reduction and treatment are different. In harm reduction, the primary goal is to manage symptoms to decrease risk whereas in treatment, the goal is to eliminate or minimize symptoms to decrease distress and impairment. For example, if we wanted to treat substance abuse, we would emphasize strategies to eliminate drug-seeking and drug-using behaviors with the overarching goal to stop these behaviors. In harm reduction, however, we would emphasize strategies that decrease the risks associated with drug-seeking and drug-using behaviors (e.g., needle-exchange programs to minimize the likelihood of infections associated with IV drug use) while assuming the person may continue to use. As you might suspect, the conversations clinicians have with a client sound quite different depending on whether the client is in treatment or in a HR approach. In treatment, the clinician likely discusses with the client those factors that contribute to his continued drug use and how to stop it. In harm reduction, the clinician is more likely to discuss the factors that place him at risk so long as he continues to use. These are quite different conversations grounded in quite different attitudes toward the problem.

However, we cannot always neatly separate these approaches (harm reduction and treatment). In a methadone clinic (another example of a harm reduction approach), when the client comes to the clinic, the staff makes some effort to provide treatment, or to open the door to treatment. Some people have coined the term “harm reduction psychotherapy” (Denning, 2000; Tatarsky, 2002) to describe how they treat the substance abuse of clients who are also enrolled in harm reduction programs. Harm reduction psychotherapy refers to an approach that recognizes that drug and alcohol problems (like other health and social problems) affect not only individuals, but also families and society. Interventions, then, target any or all of these areas. Harm reduction psychotherapy is pragmatic and compassionate. Pragmatic, in that it accepts that people choose to engage in high-risk behaviors and compassionate in that the overarching goal is to help people reduce the harm associated with their high-risk behaviors so long as they choose to continue the behaviors.

Now, let us apply this thinking to severe hoarding. Perhaps the single most important distinction between HR and treatment as applied to severe hoarding is that HR does not strive to alter the underlying mechanisms presumed to maintain the problem. For example, cognitive-behavior therapy for hoarding is an effective treatment that strives to alter the thoughts, beliefs, and behavioral patterns presumed to maintain the hoarding problem (Muroff et al., 2009; Steketee, Frost, Wincze, Greene, & Douglass, 2000; Tolin, Frost, & Steketee, 2007). However, treatment rests on the assumption that the individual, at least to some degree, is open to learning these skills in the service of managing the hoarding problem. HR, on the other hand, assumes that the individual is not open to altering the factors that maintain the hoarding problem but he may be more open to receiving help from others who will use their skills and resources to manage the hoarding problem for him. In a sense, we only ask the client to permit us to help him. We do not assume he is motivated to learn skills to manage the problem himself. For example, rather than teaching the person to organize his possessions, we provide him with organizational systems and only ask him to use them or to permit us to use them to help organize his environment. We might tack a basket on the back of the front door to hold medications, checkbook, eyeglasses, or other important items. We might label foods with an expiration or discard date and ask only that the individual permit us to discard the food when the date arrives.

A second difference between treatment and HR is that treatment tends to be of a fixed duration. For example, the group treatment of compulsive hoarding is 16 sessions plus two home-visits (Muroff et al., 2009) and may include follow-up or relapse prevention sessions after treatment ends. Individual treatment is 26 sessions over 7–12 months (Tolin et al., 2007). Typically, the treatment of hoarding takes much longer than the treatments of other psychological conditions, often as long as a year, even for those who are quite motivated (Tolin et al., 2007). Nevertheless, whether it is 16 or 26 sessions, the treatment does end. However, HR, which focuses on minimizing harm by managing the condition, goes on as long as the person is at risk. This, of course, requires the considerable time and dedication from the clinician as well as other professionals and is the rationale for a team approach to the problem, which distinguishes HR again from typical treatments for the condition.

The final difference between treatment and harm reduction is that in treatment, a clinician (or group of clinicians) is in charge of the treatment plan. In treatment, a clinician evaluates the client, recommends a treatment plan and she may provide that treatment herself. In this way, the role of the clinician is quite clear. In harm reduction, on the other hand, when a clinician is involved, she is both a mental health clinician and a consultant to the harm reduction team. Furthermore, a HR team includes not only the mental health clinician but also other professionals with quite different skills. A typical HR team might include professional organizers, visiting nurses, in-home health aides, or trusted friends and family members of the client. Although many clinicians include other forms of assistance in the treatment plan for a client with a psychological disorder, the clinician is typically in charge of the plan. In Chap. 4 (The Harm Reduction Process), we will say more about the role of the clinician and other professionals in the harm reduction approach, but for now, I view HR as a collaborative team approach with the team, including the client, managing the HR plan rather than just the clinician managing the plan.

In summary, HR assumes that a person with a severe hoarding problem is not open to working to alter the underlying thinking patterns that maintain the hoarding behavior and, therefore is not open to treatment in the way we think of treatment. In fact, HR assumes that the person with severe hoarding is not interested in changing these patterns, may not be capable of changing these patterns, and to try to change these patterns may increase defensiveness and help refusing behavior. Furthermore, although treatment for hoarding ends, HR does not and continues so long as the person is at risk because of the hoarding behavior.

At this point, you have learned that HR differs from traditional ways of helping those who suffer with a hoarding problem, such as psychotherapy and later in the book you will learn to develop a HR plan to manage a severe hoarding problem. Before I describe how you can develop and implement a HR plan, I wish to mention something I believe is as important as the plan itself, that is, the attitude with which the clinician and other members of the HR team carry out the plan. Developers of HR based the approach on a set of principles, values, and assumptions (Denning, 2000) that I have applied to the problem of severe hoarding. I call this the “harm reduction attitude.”